A breath of fresh air: a quality-improvement study comparing an air-circulating technique versus conventional technique to prevent nasogastric tube dysfunction.

BACKGROUND: Nasogastric tubes are an important component of care in patients with gastrointestinal obstructions. However, they are prone to malfunction despite conventional flushing techniques, with potentially severe consequences. There is no widely accepted, gold-standard way to ensure that a nasogastric tube succeeds in maintaining an empty stomach following flushing. METHODS: We have developed a flushing technique to better ensure successful tube function. We compared this technique to conventional flushing both in vitro (using a plastic stomach model) and in vivo (in a pig model), and we provide a didactic video. RESULTS: The mean gastric residual volume following our novel flushing technique is nearly 25-fold lower than following conventional flushing (13 mL vs. 330 mL). CONCLUSIONS: Our simple technique is more effective than conventional techniques in maintaining nasogastric tube function and therefore should prevent dangerous vomiting and aspiration pneumonia better than conventional techniques.

Pneumatosis and portal venous gas: do CT findings reassure?

BACKGROUND: Small, single-institution studies have suggested risk factors for bowel ischemia/necrosis (I/N) in patients with computed tomography (CT) findings of pneumatosis (PN) and portal venous gas (PVG). Here, analysis has been expanded in a large, multicenter study. MATERIALS & METHODS: Logistic regression models and receiver operating characteristic curves were used to construct a scoring system for I/N in cases of PN/PVG. RESULTS: Of 265 patients with PN/PVG identified, 209 had adequate data. In unadjusted analyses the following variables were significantly associated with I/N: age, peritoneal signs, ascites, the presence of both PVG and PN, blood urea nitrogen (BUN), CO2, albumin, and a history of hypertension, myocardial infarction, or stroke. In contrast, the CT findings of mesenteric stranding, bowel-wall thickening, and type of PN were not associated with I/N. In adjusted analyses, three variables were significantly associated with I/N: age ≥60 y (odds ratio = 2.51, 95% confidence interval: 1.26-4.97), peritoneal signs (10.58, 4.23-26.4), and BUN >25 mg/dL (3.08, 1.54-6.17), whereas presence of both PN and PVG (versus only one) was associated with an increase (but not statistically significant increase) in odds (2.01, 0.94-4.36). Although several ad hoc models were used to maximize diagnostic ability, with maximal odds ratio = 174, the areas of receiver operating characteristic curves were all below 0.80, revealing suboptimal accuracy to diagnose I/N. CONCLUSIONS: Older age, peritoneal signs, and high BUN are associated with I/N, suggesting an ability to predict which patients need operation. CT findings traditionally suggestive of ischemic PN/PVG, however, do not diagnose I/N accurately enough to reliably identify patients needing operation.

Simultaneous Ovarian and Renal Vein Thrombosis as a Rare Cause of Postoperative Pain After Sigmoid Colectomy.

Post operative pain is often the cause of many ED visits. When patients are discharged and return with postoperative abdominal pain, common etiologies include incisional pain, neuropathic pain, musculoskeletal pain from immobility, ileus, and more sinister causes including adhesive bowel obstruction, abscess formation, and anastomotic leak. We present a 62 year-old female without any hereditary thrombophilia or other prothrombotic factors who presented to the ED after a sigmoid colectomy and diverting ileostomy for perforated diverticulitis and subsequent ileostomy reversal with abdominal pain. CT discovered a left ovarian vein thrombus extending into the left renal vein. With a myriad of diagnoses, it is important to have a low threshold for imaging to rule out serious pathology and also diagnose any unusual causes that can be treated promptly to prevent organ damage and subsequent complications.

Primary squamous cell carcinoma at ileostomy site. Two case reports and review of literature.

SCC at ileostomy is rare, early diagnosis by sampling abnormal tissue around ileostomy is vital.

Colorectal liver metastases.

The diagnosis and management of CRLM is complex and requires a multidisciplinary team approach for optimal outcomes. Over the past several decades, the 5-year survival following resection of CRLM has increased and the criteria for resection have broadened substantially. Even patients with multiple, bilateral CRLM, previously thought unresectable, may now be candidates for resection. Two-stage hepatectomy, repeat curative-intent hepatectomy, and even selected resection of extrahepatic metastases have further increased the number of patients who may be treated with curative intent. Multiple liver-directed therapies exist to treat unresectable, incurable patients with adequate survival benefit and morbidity rates.

Diagnosis and management of cystic lesions of the pancreas.

Pancreatic cysts are challenging lesions to diagnose and to treat. Determining which of the five most common diagnoses-pancreatic pseudocyst, serous cystic neoplasm (SCN), solid pseudopapillary neoplasm (SPN), mucinous cystic neoplasm (MCN), and intraductal mucinous papillary neoplasm (IPMN)-is likely the correct one requires the careful integration of many historical, radiographic, laboratory, and other factors, and management is markedly different depending on the type of cystic lesion of the pancreas. Pseudocysts are generally distinguishable based on historical, clinical and radiographic characteristics, and among the others, the most important differentiation is between the mucin-producing MCN and IPMN (high risk for cancer) versus the serous SCN and SPN (low risk for cancer). EUS with FNA and cyst-fluid analysis will continue to play an important role in diagnosis. Among mucinous lesions, those that require treatment (resection currently) are any MCN, any MD IPMN, and BD IPMN larger than 3 cm, symptomatic, or with an associated mass, with the understanding that SCN or pseudocysts may be removed inadvertently due to diagnostic inaccuracy, and that a certain proportion of SPN will indeed be malignant at the time of removal. The role of ethanol ablation is under investigation as an alternative to resection in selected patients.